Fat Land: How Americans Became the Fattest People in the World

America is suffering an epidemic of obesity and we are fast catching up. This is an account of the history and biology of the fattening of America at the moment when it is emerging as a political issue too.

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About the Author:

GREG CRITSER is a longtime chronicler of the modern pharmaceutical industry and the politics of medicine. His columns and essays on the subject have appeared in Harper's Magazine, USA Today, the Wall Street Journal, the L.A. Times, and elsewhere. Critser is the author of Fat Land: How Americans Became the Fattest People in the World (Houghton Mifflin), which the American Diabetes Association called "the definitive journalistic account of the modern obesity epidemic." He lives in Pasadena, California, with his wife, Antoinette Mongelli.

INTRODUCTION Obesity is the dominant unmet global health issue, with Western countries topping the list. — World Health Organization

Set the soul of thy son aright, and all the rest will be added hereafter! — Saint John Chrysostom

This book is not a memoir, but it is undeniably grounded in a singular personal experience. My experience was not, for those hoping for something juicy, a moment of childhood drama. Nor was it anything that led to any form of spiritual or true psychological revelation. Compared to the harrowing tribulations that so much of the world"s population endures, it was, when all is said and done, rather mundane and petty. Here it is: Some guy called me fatso. Specifically, he screamed: "Watch it, fatso!" Here I should note that I deserved the abuse; after all, I had opened my car door into a busy street without looking into my side mirror first, and so had nearly decapitated the poor fellow. I could have killed him. But why . . . fatso? Could it be because I was indeed forty pounds overweight? Or that I could not fit into any of my clothes, even the ones I got at the Gap that were labeled "relaxed" (which, come to think of it, I wasn"t), let alone the ones considered "baggy" (which, again come to think of it, I was)? Could it be because I had to back up ten feet so as to get my entire face into the bathroom mirror to shave every morning? Or that when I dined with friends they hid their small pets and seemed to guard their plates, one arm curled around them, as if I might plunge my fork into their juicy pieces of duck and make off with them? I"m obviously joking about the latter, but the point is that the insult hit home. In upwardly mobile, professional America, being fat — and having someone actually notice it and say something about it — is almost as bad as getting caught reading Playboy in your parents" bedroom when you"re ten. Shame shame shame. Fatness was hardly a new issue for me. My wife and my physician had been after me for some time to do something about my problem, the former quite gingerly, the latter not so. My doctor, in fact, had recently suggested that I consider a new weight loss medication. At the time, I had promptly brushed the idea aside. Now, the sting still fresh, I reconsidered: Why not? And so, for the next nine months, I put all of my extra energy into the task of shedding my excess avoirdupois. In modern America, this, I would find, was a rite in itself, replete with its own social institutions (health clubs), tonics (Meridia), taboos (Krispy Kreme), and aspirational totems (Levi"s 501 regular cuts). I was apparently ready for this rite, for, to my delight, I slowly but surely lost the weight. What followed was encouraging, if somewhat predictable: congratulations from friends for "sticking to it"; enhanced self-esteem; a new wardrobe; a newfound confidence and spring in my step; phone calls from J.Lo. and Julia. Yet the more I contemplated my success, the more I came to see it not as a triumph of will, but as a triumph of my economic and social class. The weight loss medication Meridia, for example, had been effective not because it is such a good drug; even its purveyors freely admit it is far from effective for most people. What had made the drug work for me was the upper-middle-class support system that I had brought to it: a good physician who insisted on seeing me every two weeks, access to a safe park where I would walk and jog, friends who shared the value of becoming slender, healthy home-cooked food consumed with my wife, books about health, and medical journals about the latest nutritional breakthroughs. And money. And time. I wrote about these insights, first for a local magazine, then in my column in USA Today, where I write about the politics of health. I then moved on to other topics. As is the case with most subject matter, fatness had remained, at least for me, somewhat abstract, distant — intellectual rather than emotional. It was certainly nothing one could view as a matter of national urgency. Then, two things happened which would change that. For one, I met a man named James O. Hill. Hill is a physiologist at the University of Colorado"s Health Sciences Center. Curly-haired, a bit provocative, Hill is a vigorous, intellectually engaged fellow with an agile debating style and a wide-ranging presence in his field. Hill"s field is the study of obesity, everything from its epidemiology to its causes to its treatment. It was Hill who, only a few years ago, coined what may be the single most quoted line in regard to today"s soaring obesity rates. "If obesity is left unchecked," he told the Associated Press, "almost all Americans will be overweight by 2050." Becoming obese, he went on, "is a normal response to the American environment." With a presence on all of the leading public health committees charged with doing something about the nation"s expanding waistline, Hill is the dean of obesity studies. It was my fortune to meet him at just the right time. Hill spelled out the problem more clearly than anyone else. "See, for decades, most of us believed that the rate of overweight in this country was relatively static — somewhere around 25 percent of the population would be always overweight," he recalled one day. "But then, beginning in the late eighties, we started seeing that rate spike upward, 30, 35, 40 percent. And that started freaking a lot of us out. Where were the gains coming from? We know that obesity has a strong genetic component, but twenty years — anyone knows that is a laughingly small amount of time for genetics to change so much. So for the guys like myself, the question has become, basically, what has changed in the environment to allow the inclination toward overweight and obesity to express itself? What changed around us to allow us to get so big?" Big, of course, is putting it mildly. Today Americans are the fattest people on the face of the earth (save for the inhabitants of a few South Seas islands). About 61 percent of Americans are overweight — overweight enough to begin experiencing health problems as a direct result of that weight. About 20 percent of us are obese — so fat that our lives will likely be cut short by excess fat. More than 5 million Americans now meet the definition of morbid obesity; they are so obese that they qualify for a radical surgical technique known as gastroplasty, wherein the stomach is surgically altered so as to keep food from being digested. (The American Bariatric Society, whose members perform gastroplasty, reports that its waiting lists are months long and that its surgeons "can"t keep up.") Children are most at risk from obesity. About 25 percent of all Americans under age nineteen are overweight or obese, a figure that, Hill points out, has doubled in thirty years. That one figure recently moved U.S. Surgeon General Dr. David Satcher to declare obesity to be a national epidemic. "Today," he told a group of federal bureaucrats and health policy officers, "we see a nation of young people seriously at risk of starting out obese and dooming themselves to the difficult task of overcoming a tough illness." Obesity itself is slowly moving into the middle and upper classes, but the condition disproportionately plagues the poor and the working poor. Mexican American women aged 20 to 74, for example, have an obesity rate about 13 percent higher for those living below the poverty line versus those above the poverty line. Diabetes occurs at a rate of 16 to 26 percent in both Hispanic and black Americans aged 45 to 74, compared to 12 percent in non-Hispanic whites of the same age. Yet most of America — particularly the America of the Me Generation — seems to be in deep denial about the class and age aspects of obesity. Get a group of boomers together and, within minutes, the topic of obesity shifts not to medical issues but, rather, to aesthetic and gender issues, to the notion — widely held in the urban upper middle class — that "talking too much about obesity just ends up making kids have low self-esteem." Or that it "might lead to anorexia." Those attitudes also permeate the medical sphere; doctors and other health care providers remain either in ignorance or outright denial about the health danger to the poor and the young. In a rare moment of industry scrutiny a few years ago, the Centers for Disease Control surveyed twelve thousand obese adults to find out what, exactly, their doctors were telling them. The results were arresting. Fewer than half reported being advised to lose weight. A separate study sharpened the indictment: Patients with incomes above $50,000 were more likely to receive such advice than were those with incomes below. As the Journal of the American Medical Association noted, "The lower rates of counseling among respondents with lower education and income levels . . . are particularly worrisome, because members of lower socioeconomic groups have poorer health outcomes." Yes, worrisome. Yet we Americans are inured to such dirges, which daily seem to well up from the pages of our newspapers. Certainly I was. Until, that is, the unexpected intruded. It happened in the Intensive Care Unit of Los Angeles County/USC Medical Center, one of the nation"s busiest hospitals. I was there visiting an ailing relative when, suddenly, a gaggle of interns, nurses, and orderlies pushed a gurney through the ward. On it lay a very large young man, perhaps 450 pounds, hooked to the ganglia of modern medicine. He had just undergone an emergency gastroplasty repair, and it did not look good. As I came to learn, first through bits and pieces exchanged by the ward nurses, then through comments by the patient"s parents, it was not the first emergency for this man. As his mother, a modestly dressed woman in her forties, moaned at one point, "Second time in three months . . . his stomach keeps coming unstapled" (not all forms of gastroplasty actually involve stapling, as did older forms of obesity surgery, but many still refer to it that way). The woman then leaned on the shoulder of her weary husband. "My . . . boy." Her boy was dying from his own fat. Yes, he was dying, and yes, the more I looked, the more I could see: Here was someone"s boy, one plagued, I imagined, by years of bad health, discomfort, self-loathing, and, of course, countless insults and snickers by passersby and friends alike. But someone"s little boy nonetheless. Watching him as he gasped for air — respiratory function is one of the first things that can go when one gets so big — I could not help think: There but for the grace of God go I. And, to hear Jim Hill and Dr. Satcher tell it, a large number of other decent Americans. Driving home that night, through the barrio of East L.A., then up the chilly black Pasadena Freeway to the town where I live, I wondered just how a boy becomes so disabled. Genes certainly played a role, but as Jim Hill had lucidly pointed out, genes have always played a role in obesity. The question was, why are we seeing so many more people like the one I just saw? How — exactly — had they been made? And if it is true that, in America, every man is his own author, that every man, as Ivan Illich once wrote, "is responsible for what has been made of him," then what, as a nation, is being made of us by the obese? I decided to find out: How is it that we better-off Americans, perhaps the most health-conscious of any generation in the history of the world, have come to preside over the deadly fattening of our youth and their future? That is the story you will read on the following pages, and that is why we must now turn to the strange career of one Earl L. Butz . . .